Provider Demographics
NPI:1083289110
Name:FAGER, MIKAILA (MS, SLP-CCC)
Entity Type:Individual
Prefix:
First Name:MIKAILA
Middle Name:
Last Name:FAGER
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:MIKAILA
Other - Middle Name:
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CEREBRAL PALSY, INC
Mailing Address - Street 2:2801 S WEBSTER AVE
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-337-1121
Mailing Address - Fax:920-337-1126
Practice Address - Street 1:CEREBRAL PALSY, INC
Practice Address - Street 2:2801 S WEBSTER AVE
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-337-1122
Practice Address - Fax:920-337-1121
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235Z00000X
WI5262-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist